The device is checked and programmed immediately following implantation You will receive and information brochure and a card for your wallet recording details of the device It may be rechecked the following morning if there are any concerns or a need to make further adjustments This is done easily by direct communication between the device and a computer positioned near the patient A further follow up is done at 12 weeks following the implant to check if the leads have settled in well and if the device needs any further adjustments to meet the patient`s need Thereafter follow up is yearly. This can be done remotely using the telephone Some devices allow for constant remote monitoring so as soon as a problem is detected, the patient can be asked to come in for a check up

For patients having a pacemaker or ICD implant, a follow up chest X ray will be done immediately after the implant to check the device and lead position . It is also done to exclude the possible complication of an air leak from the underlying lung. This can then be dealt with by inserting a chest drain Please don’t raise the arm on the implant side above the level of you shoulder for about 4 weeks Avoid carrying heavy objects on this side for also for about 4 weeks The dressing should remain on and be kept dry for 5-7 days and then left exposed to air dry All sutures are under the skin and are absorbed by the body Watch for signs of infection. These are: increasing pain, redness, swelling or a purulent discharge (pus) from the wound If the stitches are showing inform your physician. These should be removed to avoid tracking of infection into the pocket.

Patients should have recent blood work and a chest X ray . This will be arranged by our clinic staff for you. Don’t take breakfast on the morning of the procedure but you may take your usual medication. Generally omit anti blood clotting medication like aspirin and plavix for 5 days before the procedure unless advised by the electrophysiologist. Patients on warfarin can stay on warfarin after checking the INR trend with the electrophysiologist. Patients on newer blood thinning drugs like Pradaxa, Xeralto and Apixaban need to omit these for 24 to 48 hours before the procedure. Arrive at the booked ward early in preparation for the procedure. If this procedure is to done as a day procedure have someone drive you to and from the hospital. You will have the implant area either the left or right chest wall prepared and cleaned. Intravenous antibiotics will be given. Please notify the staff of any allergies including an allergy to plasters or latex gloves.

These are fast heart rates and can be divided into supraventricular tachycardia if arising from the top chambers of the heart or ventricular tachycardia if they arise from the lower chamber. The diagnosis can usually be made on an ECG (electrocardiogram) but it requires an electrophysiological  (EP) study to locate the exact origin of the tachycardia in order to eradicate the problem. This is done in an electrophysiology laboratory and the process of eliminating the abnormal circuit is referred as an ablation. The electrophysiology laboratory is a sterile environment where catheters are steered up to the heart through a vein or artery in the groin under X-ray guidance. The exact location of the of the cause of the tachycardia can thus be identified. This is then ablated using either by heating or freezing the tissue through a specialised catheter. Types of Ablation Technologies Radio frequency energy is used to heat and destroy tissue. Conducting tissue can also be modified by freezing. An ice ball forms at the catheter tip. This is called cryotherapy. Ablation of the underlying heart myocardium using a special ‘irrigated’ catheter. Mapping and Recording Systems The electrophysiologist relies of a host of computer systems that process the electrical activity from the heart in order to navigate to the origin of the problem. This is vital in order to perform the ablation at exactly the correct area. Ideally the tachycardia or fast heart should be induced in the EP laboratory to accurately diagnose the problem and to locate the abnormal circuit. A recording system is shown on the left while sometimes a mapping system is require for a more detailed navigation of the chambers of the heart. Normal Cardiac Conduction Normal conduction of the heart starts with an impulse generated from the natural pacemaker of the heart called the SA Node situated in the top right hand corner of the right atrium. This tells the heart at what rate to beat at. The impulse then conducts down to a structure called the AV Node to the lower chambers called the ventricles. There is usually no other means for these impulses to reach the lower chambers as the valves that divide the upper and lower chambers act as a insulation barrier. This is to protect the lower chambers from being driven too past by the SA node. Supraventricular Tachyarrhythmias This is one of the most common SVTs, occurring in both older and younger patients. The circuit causing the tachycardia is related to having  a slow pathway within the AV node. This essentially results in a short circuit within the AV Node. It is successfully treated with an ablation standing a greater than 90% chance of curing the problem. However there is a small 1% risk of damaging the normal pathway and the patient needing a pacemaker. WPW Syndrome Atrial fibrillation is the most common arrhythmia in man, effecting millions of people worldwide. In a select group this is primarily caused by trigger cells lying within the pulmonary veins which bring blood from the lungs back to the left atrium of the heart. In this patient group we are able to either cure or dramatically improve symptoms by ablating around these pulmonary veins preventing the trigger cells from activating atrial fibrillation. Transseptal Puncture Since the pulmonary veins enter the left atrium, a procedure called a transseptal puncture is performed in order to reach the veins with a catheter. A needle is advanced from the groin to the septum between the left and right atrium. A safe painless puncture is performed under ultrasound guidance.

Atrial fibrillation is the most common rhythm disorder affecting man and has a prevalence of 1-6% in the general population and the incidence increases with advancing age. The disease reduces activity of individuals in the productive years and also presents a risk of stroke and mortality. It is now possible to control and even cure some forms of atrial fibrillation through a minimally invasive procedure called a Pulmonary Vein Isolation (PVI). The rapidly advancing technology in electrophysiology may accomplish this procedure in under 3 hours with just conscious sedation (not full general anaesthetic) and can be done essential as a day procedure. The advances in the field have made the majority of electrophysiology procedures extremely cost effective with minimal patient down time. Patients can return to normal work capacity within days. The pulmonary veins are accessed through a procedure called a transeptal puncture. Once the transceptal puncture is performed, catheters are inserted into the left atrium and a map of this chamber is made using computer software. This way accurate ablation burns can be done around the veins competely isolating them. This procedure is called a pulmonary vein isolation or PVI for short. The result is a 70% chance of leaving the patient free of atrial fibrillation!

The heart has a natural pacemaker called the sinoatrial node. This is essentially a region of specialized cells responsible for generating impulses that trigger each heart beat. The impulses are conducted away from the SA node to the muscle cells of the heart by a conducting system. If there is a failure of the SA node to generate impulses or if the conducting system fails , the result is a slowing of the heart beat or even complete failure to beat. This condition is fairly common as patients get older. A pacemaker acts to generate these impulses artificially and essentially bypasses the native conducting system of the patient in order to tell the heart when to beat. This can be a life saving therapy! Pacemakers are implanted under local anaesthesia under sedation in a sterile electrophysiology laboratory or an adapted cardiovascular suite. With modern technology the technologist is able to program the pacemaker wirelessly even while the cardiologist is performing the procedure. The pacing leads are advanced through a vein under the collar bone by needle access. This, then, is a minor procedure. The pacing lead is then advanced into the vein and guided into place in the heart under X ray guidance. Pacemaker leads either passively grip the muscle strands in the right ventricle of the heart or are actively screwed into the wall lining. A pacing circuit is either set up between the pacemaker and the tip of the lead in the heart or between two electrodes at the tip of the lead in the heart. This is a more efficient way of pacing the heart. Once a pacemaker or any other cardiac device is implanted, an important component of patient care is the regular follow-up and maintenance of the implant. Afterall it is a piece of sophisticated machinery monitoring and interacting with the heart. Checkups can be done in the device clinic through Wi-Fi connectivity or even remotely using a telephone line or cellular network. This vital role is fulfilled by the electro physiologist as well as a dedicated group of trained technologists and nurses.

An Implantable Cardioverter Defibrillator (ICD) is a battery-powered device placed under your skin. It is connected to your heart by one or more wires (leads) and keeps track of your heartbeat. It is important to realise  that ICDs have the ability to pace the heart just like a pacemaker when the heart rate is too slow. In addition the ICD has the ability to stop fast, potentially lethal arrhythmias arising in the lower chambers of the heart called ventricular tachycardia (VT) or ventricular fibrillation. The ICD stops these ventricular arrhythmias either by “overdriving” the fast rate or by delivering a small shock directly into the heart thus resetting the rhythm. The ICD is implanted in exactly the same way as a pacemaker. This is done under local anaesthetic and with sedation. Recovery after the implant is very quick with patients feeling only minimal discomfort for a few days. At the implant the electrophysiologist may feel that the shock function of the device must be tested. This will be done under deep sedation with the patient asleep. This is often omitted given the high success of the device.

There are 22 million people in the world suffering from heart failure. It occurs after heart muscle damage from a heart attack, viral infection or several other causes. Patients complain about shortness of breath, swelling of legs and general lack of energy. The heart muscle is weakened and the heart enlarges, pumping less effectively. Cardiac Resynchronisation Therapy (CRT) is a form of pacing therapy where both the lower chambers of the heart (namely the left and right ventricles) are paced simultaneously. This highly effective form of therapy helps improve heart failure symptoms and can be used to delay and even replace cardia transplantation in some patients. It can only be performed in selected patients as only 60% of patients benefit from this therapy. The CRT implant is more complex than a pacemaker. A lead is first placed in the right ventricle. Then a specialized lead is placed in a vein called the coronary sinus, over the left ventricle. Finally, an atrial lead is inserted.

Cardiac mapping is almost like a GPS system for the heart. It improves the accuracy in locating arrhythmia allowing us to ablate them with better outcomes and safety. It also reduces the  x-ray dose to the patient and staff during a case.

Rhythm disorders of the heart are common in any population and the incidence is irrespective of socio-economic status. The presentation may be life impairing with symptoms of palpitations and tiredness or may present a risk of sudden cardiac death (SCD). Electrophysiology is a sub-branch of cardiology. It deals with heart rhythm disorders that encompass both slow and fast heart rates. The most recognisable context is the implantation of pacemakers in patients with abnormalities of impulse generation and conduction and this is the device management aspect of electrophysiology. The faster heart rhythms are best dealt with a procedure referred to as an ablation. This is an all-encompassing term that is obviously more complex with ablations that are highly specific relying on technology to map and identify the discreet origin of the tachycardia (fast heart rate) with steerable catheters inserted through a groin vein up to the heart under X-ray guidance. Once the source is identified then energy is applied down the catheter to a discreet location burning off or alternatively freezing the culprit region returning the heart rate to normal. These catheters are guided to the precise location by using mapping equipment which helps navigate the various chambers of the heart (figure 1). These procedures are typically conducted in an electrophysiology laboratory (figure 2). The ablation is often curative meaning that the patient requires no further medication or intervention in the majority of cases, depending on the underlying rhythm disorder. Alternatively the procedure may ameliorate symptoms thus improving the quality of life. Ablation procedure reduce morbidity but may also be lifesaving. Lethal ventricular tachycardias (arising in the lower chambers of the heart) can be the cause of sudden cardiac death. This can even be the first presentation. They can occur in patients that were previously well such as in genetically inherited conditions or after a previous heart attack or a viral infection leaving a cardiac scar which becomes electrically unstable. Sometimes the cardiac arrest can occur many months or years after the heart has sustained the injury. Even though a culprit coronary artery may be stented or grafted by a surgeon the scar remains within the myocardium and becomes the fulcrum for an electrically unstable circuit. An indicator of this risk is the measure of the contractility of the heart. In fact patients with reduced cardiac muscle contractility are regarded as high risk of sudden cardiac arrest and the recommendation is to implant a device called an implantable cardioverter-defibrillator or ICD. This device is essentially a pacemaker with all the features of a standard pacemaker but can also terminate these lethal fast rhythms by overdrive pacing the heart or delivering a small shock internally into the ventricle. This therapy has been shown to be more effective than medication and saves lives! Unfortunately the implantation rate of ICDs in South Africa is well below that of the western world and shows that we are not achieving our optimal health care objectives. Patients with ICDs require routine (usually 6 monthly) device check-ups. This is also relevant to those patients just implanted with just pacemakers as these devices now have such advanced algorithms and regular “device” check-ups are necessary to maintain standards and health of the patients.Cardiac device implantation and maintenance is the other facet of electrophysiology and is the essential outpatient service that is fundamental to any comprehensive cardiac rhythm management service. In short, all patients with cardiac devices need specialised follow–up which comprise remote trans telephonic monitoring and/or walk-in clinic attendance periodically. Most cardiology practices are ill-suited for the technical expertise required for adequate analysis or the devices or for the specific device related issues occurring in these patients. Patients are therefore implanted with no definite follow-up plan or structure and management tends to occur on an adhoc basis. The HRM team will also provide a network of Cardiac Device Clinics providing outpatient facilities. These units will be based within selected Life Health group hospitals servicing the needs of the respective community. The staffing and training of these clinics will fall on the Heart Rhythm Management team of electrophysiologists. The staff will primarily be highly trained cardiac technicians who have an interest in electrophysiology. Our vision, however will be to assimilate professional nurses who want to specialise in device management. This then creates career avenues for potential nursing staff and HRM makes a contribution to creating employment of nursing professionals. These registered nurses will have delegated duties and function as nursing practitioners within the HRM Device Clinic structure.